If you are between the ages of 18 and 69 the questionnaire will indicate if you should check with your doctor or health professional before you significantly change your physical activity patterns.

If you are over 69 years of age and are not used to being very active, you should check with your doctor or health professional. Common sense is your best guide when answering the questions.

Your NameHas your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor or health professional? Yes NoDo you feel pain in your chest when performing physical activity? Yes NoHave you experienced chest pain when NOT performing physical activity in the last month? Yes NoDo you lose your balance because of dizziness or have you lost consciousness recently? Yes NoDo you have any bone or joint problems such as arthritis, which could be aggravated through physical activity? Yes NoIs your doctor currently prescribing you medications for high blood pressure or a heart condition? Yes NoHas your doctor or health professional ever told you to NOT exercise? Yes NoIs there any reason why you should NOT participate in physical activity? Yes No

If you answered YES

If you answered YES to one or more questions OR you are concerned about your health, consult your GP before increasing your physical activity. You should ask for a medical clearance along with information about any specific exercise limitations you may have.

When to delay exercising:

If you are not feeling well because of a temporary illness, such as a cold or a fever, wait until you feel better to begin exercising. If you are or may be pregnant, talk with your doctor before you start becoming more active.

If you answered NO:

If you answered no to all the above questions, you can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowing and increase gradually. It may also be helpful to have a fitness assessment with a fitness instructor or personal trainer to determine where to begin.

PLEASE NOTE:

If your health changes so that subsequently you answer YES to any of the above questions, please inform your GP immediately and prior to resuming exercising.

I confirm that I am voluntary engaging in an acceptable level of exercise and accept that my participation involves a risk of accidents, falls and personal injury. I release, discharge and hold harmless the instructor, the facility hosting the class and any associated personnel from any and all liability, claims, demands, or causes of action that may arise from my participation in this group exercise class.

If I have answered YES to one of the above, I have sought medical advice and my GP or medical professional has confirmed that I may exercise

In the event of an emergency, I give consent for any necessary medical treatment to be administered.

I have read, understood and accurately completed this questionnaire.

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